Government to pilot patient referral system in Dhaka, Chattogram healthcare

The plan is to streamline healthcare services, where patients will first visit local health centres before going to specialised hospitals

Although integral to the nation’s health policy, the referral system has long remained a concept on paper in Bangladesh's healthcare landscape. The Awami League government’s earlier efforts to bring it to life fell short.

Now, the interim government is stepping forward to break new ground. It plans to pioneer a referral system that involves setting up dedicated healthcare centres staffed with doctors and health workers, all under a carefully crafted project.

This initiative promises to reshape the way healthcare is accessed and delivered across the country.

The government aims to implement this system to reduce unnecessary patient congestion at medical colleges, institutes, and specialised hospitals in Dhaka, ensuring better healthcare services and restoring order.

Under this system, patients must first visit local health centres before going to medical colleges, institutes, or specialised hospitals in Dhaka. Doctors at these centres will provide consultations and prescriptions, referring patients to larger hospitals if necessary.

According to Dr Sayedur Rahman, special assistant to Chief Advisor Muhammad Yunus, the referral system will be piloted in select areas of Dhaka and Chattogram within the next two to three months.

He told bdnews24.com on Tuesday that initial discussions about implementing the referral system were held in a meeting in Dhaka on Dec 19, 2024, and work on the project has since begun.

WHAT IS THE REFERRAL SYSTEM?

In this system, a patient first visits the nearest government or private primary healthcare centre. If necessary, the centre will refer the patient to a hospital equipped with advanced treatment facilities, staff, and equipment.

Major hospitals will treat patients referred from smaller hospitals and health centres, only admitting critically ill patients and sending others back to local centres.

The referral system is used globally for effective patient management and advanced treatment, ensuring that only patients needing higher-level care are transferred from one hospital to another. In countries where this system is in place, patients cannot be admitted to any hospital without a referral.

HOW IT WILL BE IMPLEMENTED

Sayedur, former vice-chancellor of Bangabandhu Sheikh Mujib Medical University, or BSMMU, has provided an outline of how the referral system will be introduced in Dhaka.

He said the system will operate on the model of a private organisation currently offering medical services based on general physician, or GP, in Dhaka.

In this system, patients can either visit health centres directly or book appointments in advance via mobile phones.

Upon arrival at the health centre, they will register using their national identification card and mobile number. A paramedic will then conduct initial tests and store the data digitally.

After this, the patient will be referred to a doctor who will prescribe treatment based on the condition or refer the patient to a specialist in a government or private hospital if needed.

Sayedur stressed the importance of establishing the initial “point of referral” at health centres.

For this purpose, a health centre will be set up for several wards around each medical college or large hospital. Under the project, each health centre will have four doctors – two male and two female – providing services from 8am to 10pm.

“The referral system cannot be launched citywide without these clinics. We are initially planning to create a network in the catchment area around one or two major hospitals to launch the GP-based referral system,” Sayedur said.

He also said staffing for these centres would be recruited under a specific project.

“We have a shortage of government doctors, so this initiative will not be run by the cadre service doctors. Recruiting new government doctors is also time-consuming. Therefore, we will create a separate General Practitioner Service.”

Sayedur pointed out that the project involves financial aspects, which are currently being evaluated. Initially, the referral system will be launched in Dhaka and Chattogram.

“Dhaka has a population of 25 million, and Chattogram 5 million. Therefore, we will pilot the referral system in these major cities, hoping to demonstrate its feasibility within three months.”

In 2014, the then health minister Mohammad Nasim announced an initiative to introduce the referral system in the Rangpur Division at an event in Rangpur Medical College Hospital.

However, due to a shortage of doctors, support staff, and other resources in primary health centres, it was not possible. Similar attempts in 2016 and 2019 also failed.

Regarding previous efforts, Sayedur said: “We are not focusing on the past. We are starting anew.”

BENEFITS OF THE REFERRAL SYSTEM

Specialised facilities like Dhaka Medical College Hospital, or DMCH, often experience an influx of patients from outside Dhaka.

According to doctors, many of these patients could have been treated at local hospitals.

On Jan 2, Prof Dr Mahmudul Haque, director of the Bangladesh Institute of Child Health, told bdnews24.com that one-third of the children visiting their emergency and outpatient departments did not need to come there.

“Some patients come to the outdoor department unnecessarily. For patients who require hospital admission or urgent ICU care, it would be better if they were referred. When beds are unavailable, admitting patients becomes challenging. A referral system reduces patient suffering,” he said.

The National Health Policy 2011 advocates for a functional referral system to facilitate the treatment of complex cases at subsequent levels in both urban and rural areas.

However, a recent study revealed that 59 percent of patients move from one hospital to another on their own, and 58 percent are unaware of the referral system.

The study, “Patient Self-Referral Patterns in a Developing Country: Characteristics, Prevalence, and Predictors,” examined data from 822 patients at DMCH and Delta Medical College Hospital in 2022. It was published in the online version of Springer Nature’s BMC Health Services Research on May 21, 2024.

Associate Prof Taufique Joarder of the National University of Singapore's Global Health Institute told bdnews24.com that the referral system is essential worldwide to control treatment quality and ensure timely healthcare delivery.

“If a patient with a common cold directly visits the most specialised doctor, it disrupts the system. The specialist cannot attend to more critical patients, depriving those in need of timely care,” he said.

He emphasised the need to improve primary healthcare services to implement the referral system effectively.

“If patients don’t get proper care or trust at the Upazila health centres, they will move to district or medical college hospitals. Enhancing primary healthcare quality is as crucial as introducing the referral system.”

Dr Abdul Hamid, chairman of the Health Economics Institute at Dhaka University, called the referral system a commendable initiative but stressed the need for sufficient primary health centres before its implementation.

“Hospitals near the patients' homes must be of good quality, and the referred hospital should prioritise referred patients.”

According to the Health Bulletin 2024 published by the Directorate General of Health Services, there are 142,000 registered doctors under Bangladesh Medical & Dental Council, or BMDC, including 13,588 Bachelor of Dental Surgery, or BDS, holders. The remaining are Bachelor of Medicine and Bachelor of Surgery, or MBBS, doctors.

The government data shows that there is one doctor for every 1,204 people, with 29,743 government doctors, equating to one government doctor for every 5,749 people.